When should I consider referring a patient with vaginismus to a specialist for further evaluation?

Consider referring a patient with vaginismus to a specialist for further evaluation if:

• There is persistent pain or sensory changes in the vagina or pelvis that are unprovoked or provoked by sexual activity, or if the pain is generalised or follows a specific nerve distribution.
• There are associated vaginal problems such as discharge, bleeding, or painful sexual intercourse that do not resolve with initial management.
• There are urinary or bowel symptoms accompanying the vaginismus, such as recurrent infections, incontinence, retention, or pain during voiding or defaecation.
• Initial management in primary care, including pelvic floor muscle training or behavioural interventions, has not improved symptoms.
• There is suspicion of underlying neurological disease or complex pelvic floor dysfunction requiring multidisciplinary assessment.
• The patient has a history of pelvic surgery, mesh implantation, or other pelvic floor complications that may contribute to symptoms.

Referral should be made to a specialist such as a urogynaecologist, gynaecologist with expertise in pelvic floor dysfunction, or a multidisciplinary pelvic floor team for comprehensive assessment and management.

This approach ensures that complex or refractory cases of vaginismus receive appropriate specialist evaluation and tailored treatment plans.

References: NICE NG123,NICE NG210